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Real-life experience to improve endoscopy outcomes: optimising teamwork and metrics
The degree of patient co-morbidity is well recognised as significant contributor to the outcome of patients presenting with an upper gastrointestinal bleed (UGIB). In this edition of Frontline Gastroenterology Taha et al1 have published a single centre series of 2669 patients over 15 years which confirms the impression of frontline endoscopists that the patients they are seeing are getting increasingly more complex and more unwell. They also suggest that the introduction of a multidisciplinary approach for this growing complexity of case-mix has resulted in improved outcomes. The journal has published several high quality articles looking at provision of UGIB services, and this paper adds to that in helping define what a multidisciplinary approach can bring to this common problem.
We have also published a series of articles on quality improvements in colonoscopy, and are delighted to publish more in this edition to complement those. Vaughan-Shaw et al2 have investigated a large series of repeat colonoscopies from a single endoscopy training centre over three years. With the burgeoning of possible metrics of colonoscopy outcome it is proposed that the detection of new pathology in such repeat procedures be included. Another aspect of quality improvement that we can learn from in endoscopy is the improvements in surgical safety brought about by the introduction of checklists. The St Mark's group have implemented such an endoscopy unit checklist and Matharoo et al3 describe the lessons learned from their experience. As well as sharing the checklist itself they also provide a videolink to demonstrate its utility and potential to improve safety and teamwork.
Increasing patient choice through tailoring pain relief is another potential key metric in endoscopy units. Ball et al4 report a survey of UK bowel cancer screening colonoscopists in the UK which highlights that whilst Entonox is generally thought to be effective and convenient, it is used relatively infrequently. Interestingly, most colonoscopists would opt to receive Entonox themselves if they had to have the procedure. The final themed article in this edition is the Curriculum Based review (with BMJ Learning module online) by Mohanaruban et al.5 They provide a practical and complete review of the process of consenting for endoscopy.
Risk stratification in the assessment of iron deficiency anaemia
If upper GI bleeding is the most frequent component of the acute gastroenterology workload, a matching clinic issue is that of iron deficiency anaemia (IDA). A way of risk stratification therefore holds potential to rationalise investigations in this common condition. Undertaking careful analysis of a large cohort of patients presenting over an eight year period, Snook et al6 have identified three key, simple, clinical variables that predict the likelihood of GI malignancy in patients presenting with IDA: do read the article to find out what those are… The potential for developing a scoring system to investigate IDA—similar to those developed for upper GI bleeds—is raised by the robust statistical analysis presented by the authors.
Another potentially cost effective way of approaching IDA is to utilise faecal occult blood testing of stool. The UK bowel cancer screening programme has shown that this test may be of great value when used in a focussed manner. Chowdhury et al7 explore the value of faecal occult blood testing in IDA, showing that a negative test has a 99% sensitivity at excluding colonic disease by colonoscopy. Given the costs and intrusiveness of colonoscopy in this often multiply co-morbid population, it is possible that faecal occult blood testing may represent a viable screening tool.
Treatment of Non-Alcoholic Fatty Liver Disease
This edition's focus on common clinical scenarios includes a review of the increasingly prevalent problem of non-alcoholic fatty liver disease (NAFLD). Dyson et al8 have summarised a large body of research to provide a hands-on management approach based on meticulous risk-stratification (as per the publication by the same authors in the last edition of Frontline Gastroenterology). They provide an evidenced approach to care based on addressing four main targets of therapy in patients with NAFLD: lifestyle modification, aspects of the metabolic syndrome, liver-directed pharmacotherapy and the complications of cirrhosis.